IV Vitamin Infusion Therapy

Medical History Form
Please enable JavaScript in your browser to complete this form.

Contact Details

Home Address

Do we have permission to contact you electronically?

By Email
By Text

Details of person to contact in an emergency:

Medical History

1) Are you receiving any medical treatment at the present time
2) Have you been a patient in hospital during the past two years?
3) Are you currently taking any medications?
4) Do you have any allergies?
5) Have you experienced any allergies or unusual side effects from any tablets, drugs, injections or anaesthetic?
6) Are you currently pregnant or breastfeeding?
7) Are you, or have you been under the care of a Doctor during the past two years?

8) Have you ever had or currently have any of the following? If so, please tick as appropriate:

Heart
Chest
Blood
Other

Vitamin IV Infusion Therapy – Treatment History

1) Have you ever had a vitamin IV infusion?
2) Have you had any problems with prior infusions including reactions or access issues?
5) Do you currently take any vitamin supplements?
Please indicate if you experience any of the following symptoms:

I confirm that I have read and understood this medical form. I confirm to the best of my knowledge; this is a true and accurate description of my medical history and current conditions.

 I understand that withholding any information may be detrimental to my health during the procedure.  If there is any change in my medical history, it is my responsibility to inform my practitioner.

Please enable JavaScript in your browser to complete this form.

Contact Details

Home Address

Do we have permission to contact you electronically?

By Email
By Text

Details of person to contact in an emergency:

Medical History

1) Are you receiving any medical treatment at the present time
2) Have you been a patient in hospital during the past two years?
3) Are you currently taking any medications?
4) Do you have any allergies?
5) Have you experienced any allergies or unusual side effects from any tablets, drugs, injections or anaesthetic?
6) Are you currently pregnant or breastfeeding?
7) Are you, or have you been under the care of a Doctor during the past two years?

8) Have you ever had or currently have any of the following? If so, please tick as appropriate:

Heart
Chest
Blood
Other

Vitamin IV Infusion Therapy – Treatment History

1) Have you ever had a vitamin IV infusion?
2) Have you had any problems with prior infusions including reactions or access issues?
5) Do you currently take any vitamin supplements?
Please indicate if you experience any of the following symptoms:

I confirm that I have read and understood this medical form. I confirm to the best of my knowledge; this is a true and accurate description of my medical history and current conditions.

 I understand that withholding any information may be detrimental to my health during the procedure.  If there is any change in my medical history, it is my responsibility to inform my practitioner.

Instagram